DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
921766 A. BUILDING __________
B. WING ______________ 		02/16/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
UNICARE HOSPICE PROVIDER, INC 870 N MOUNTAIN AVE, SUITE 208, UPLAND, CA, 91786
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0520      
33786 Based on observation, interview, and record review, the Condition of Participation L520 418.54 Initial and Comprehensive Assessment of the Patient was not met as evidenced by: 1. The agency failed to ensure Dulcolax (a medication used for constipation) was available for use as prescribed by the physician for Patient 1. (Refer to L 530) 2. The agency failed to ensure a wound cleanser, TAO (triple antibiotic ointment- a medication used to treat to skin wounds) and dry dressing (a covering to prevent the wound from injury, prevent introduction of bacteria and assist with healing) were available for use as prescribed by the physician for Patient 1. (Refer to L 530) 3. The agency failed to ensure the frequency of the wound treatment was included in the physician's orders. (Refer to L 530) These cumulative effects of these systemic problems resulted in the failure for Patient 1's needs to be met.
L0530      
33786 Based on observation, interview, and record review, the agency failed to ensure the following for Patient 1: 1. The medication Dulcolax (a medication used for constipation) was available for use as prescribed by the physician. 2. The wound cleanser, TAO (triple antibiotic ointment- a medication used to treat to skin wounds) and dry dressing were available for use as prescribed by the physician. 3. The frequency of the wound treatment was included in the physician's orders. Findings: 1. During a review of Patient 1's face sheet (a document that contains patient's information), undated, indicated a start of care date March 18, 2021, with a recertification period of March 18, 2021 to June 15, 2021. Patient 1 had a diagnoses which included muscle weakness, hypertension (high blood pressure) and edema (a condition where there is excessive fluid). During a review of Patient 1's medication profile noted a physician's order dated, March 18, 2021, which indicated, "Dulcolax 10 mg (milligram-a unit of measurement) rectal suppository daily PRN (as needed)." During a home visit on April 13, 2021 at 11:15 AM, with a Registered Nurse (RN 1), Patient 1's medications were reviewed. The medication Dulcolax 10 mg rectal suppository was not available. During an interview with Patient 1's daughter on April 13, 2021 at 11:25 AM, she stated, "I cannot find the Dulcolax in the refrigerator." During an interview with RN 1 on April 13, 2021 at 11:30 AM, RN 1 confirmed the family cannot find the Dulcolax. RN 1 further confirmed the medication is not available during the home visit. RN 1 stated, "The Dulcolax should be available." During a review of the facility's policy and procedure titled, "Verification of Physician Orders," revised April 2013, indicated, "To ensure that accurate physician orders and prescriptions are obtained in accordance with state and federal law and regulation." During a review of the facility policy and procedure titled, "Medication Profile," revised April 2013, indicated, "For accuracy and to completely reconcile medications across the continuum of care, the admitting organization will obtain and document a complete list of the patient's current medications upon the patient's entry to the organization. A comparison of the medications ordered for the patient while under the organization's care will be made to those on the list." 2. During a review of Patient 1's face sheet (a document that contains patient's information), undated, indicated a start of care date March 18, 2021, with a recertification period of March 18, 2021 to June 15, 2021. Patient 1 had a diagnoses which included muscle weakness, hypertension (high blood pressure) and edema (a condition where there is excessive fluid). During a review of Patient 1's medication profile noted a physician's order dated, April 9, 2021, indicated, "Left Shin: cleanse with wound cleanser, pat dry, apply TAO (Triple Antibiotic ointment) and cover with dry dressing x 7 days." During a home visit on April 13, 2021 at 11:45 AM with a Registered Nurse (RN 1), Patient 1's medications were reviewed. The wound cleanser, dry dressing, and the TAO were not available for use as ordered by the physician. During an interview with RN 1 on April 13, 2021 at 11:45 AM, RN 1 confirmed the wound cleanser, dry dressing, and TAO were not available. RN 1 stated, "The wound cleanser, dry dressing, and TAO should be available. The supplies should have been ordered from the pharmacy." During a telephone interview the Licensed Vocational Nurse (LVN 1) on April 14, 2021 at 10 AM, LVN 1 confirmed the wound cleanser, dry dressing, and TAO were not ordered from the pharmacy. LVN 1 stated, "I did not order the supplies from the pharmacy." During a review of the facility's policy and procedure titled, "Verification of Physician Orders," revised April 2013, indicated, "To ensure that accurate physician orders and prescriptions are obtained in accordance with state and federal law and regulation." During a review of the facility policy and procedure titled, "Medication Profile," revised April 2013, indicated, "A comparison of the medications ordered for the patient while under the organization's care will be made to those on the list." 3. During a review of Patient 1's face sheet (a document that contains patient's information), undated, indicated a start of care date March 18, 2021, with a recertification period of March 18, 2021 to June 15, 2021. Patient 1 had a diagnoses which included muscle weakness, hypertension (high blood pressure) and edema (a condition where there is excessive fluid). During a review of Patient 1's treatment profile noted a physician's order dated, April 9, 2021, indicated, "Left shin: cleanse with wound cleanser, pat dry, apply TAO (Triple Antibiotic Ointment-a medication used to treat skin infections), and cover with dry dressing x 7 days." There is no frequency in Patient 1's physician orders. During an interview with RN 1 on April 13, 2021 at 12:10 PM, RN 1 confirmed there is no frequency in the physician's order. RN 1 stated, "There should be a frequency in the physician's orders." During a telephone interview the Licensed Vocational Nurse (LVN 1) on April 14, 2021 at 10:15 AM, LVN 1 confirmed the physician's order did not included a frequency. LVN 1 stated, "I forgot to put the frequency." During an interview with Patient Care Coordinator (PCC 1) on April 14, 2021 at 10:30 AM, PCC 1 confirmed there is no frequency in the physician's order. PCC 1 stated, "There should be a frequency." During a review of the facility's policy and procedure titled, "Verification of Physician Orders," revised April 2013, indicated, "2. Complete medication orders will include the indications for use, dose, frequency, route, rate of administration and when generic or brand names are acceptable or required."